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Remember how we always tell you - Share all your medical conditions, lifestyle details, etc. when filling out your health insurance proposal form? This ensures that the insurer is aware of your condition, and provides coverage accordingly. But what if, even after making honest declarations, your claim is rejected on the grounds of “non-disclosure”?! 😨

Mr Ram Swaroop Singh Chauhan was struggling with this very question when he received a rejection letter from his health insurance company. His heartbreak began when his wife, Meenu Chauhan, fell seriously ill and had to be hospitalized. Despite all medical efforts, she had to be shifted to another hospital - where she tragically lost her life. 💔

Amidst his grief, Ram Swaroop filed a claim of Rs 4,33,495 under their family floater health insurance plan. Since he had always been diligent about their policy, he expected a smooth claim settlement. But instead, he faced another devastating blow - the claim was denied. 😢 And the reason was even more shocking!

The insurer cited undeclared elevated creatinine levels, which they claimed indicated Chronic Kidney Disease (CKD). But according to Ram Swaroop, she wasn't suffering from CKD - but from Diabetes and its complications, which he had clearly declared at the time of policy purchase.  🫤

Elevated creatinine levels, sleep disorders, and urinary problems are all complications of Diabetes.  💊 The insurer had accepted the policy with full knowledge of her Diabetes - and even charged a higher premium for it! So how could they now claim he hid information, and reject his claim?

The matter was taken to the Ombudsman’s court. The Ombudsman demanded that the insurer justify their claim rejection. Here’s what they said...

🏢 According to the insurer, Ram Swaroop and Meenu purchased the policy on December 1, 2018. 🏢 A year later, Meenu was hospitalised and lost her life due to multiple health conditions. Her death summary from the hospital mentioned Chronic Kidney Disease (CKD) and Diabetes Mellitus among other complications as reasons for death.

🏢 During their investigation, the insurer found that Meenu’s creatinine levels had been elevated since December 6, 2018. This suggests that she likely had CKD before purchasing the policy.

🏢 The proposal form had a specific question: "Has any member covered under the policy suffered from a renal (kidney) disorder?" Ram Swaroop had answered "No" to this question.

🏢 As per Condition No. 6 of the policy, the insurer had the right to reject any claim if false information was provided at the time of purchase. Based on this, they denied the claim. However, after hearing it all and investigating themselves, the Ombudsman spotted a major loophole…

Ombudsman pointed out two crucial facts: 🧑‍⚖️ Meenu was not diagnosed with CKD before buying the policy - so it wasn't declared. All other PEDs and medical conditions she had, were already disclosed by Ram Swaroop.

🧑‍⚖️ The insurer had already accepted diabetes and all its complications - and charged extra to give the policy! So how could they suddenly exclude CKD, which is a known complication of diabetes? The verdict was now clear…

The Ombudsman ordered the insurer to pay the admissible claim amount to Ram Swaroop within 30 days. Justice was served. ⚖️ What did we learn from the story?

✅ ALWAYS MAKE HONEST DECLARATIONS! To answer the question we started with: Can an insurer deny your claim even if you made honest declarations? - The answer is - NO!

Once you declare any medical condition, and the insurer accepts your application based on it, they cannot reject your claim citing that same disease or its known complications. This is your legal right!

✅ If your claim is unfairly rejected, escalate it to grievance redressal authorities. If you have been honest and your claim is admissible, the law will ensure you get what’s rightfully yours.

⚖️ You can first escalate your issue to the insurer's grievance redressal officer. ⚖️ If they don’t resolve your issue, you can approach the IRDAI. ⚖️If even there you don’t get a solution, you always have the Ombudsman to fight for your rights!

✅ From buying the right insurance to claiming what’s rightfully yours, having an expert advisor can make all the difference! An advisor guides you through understanding insurance plans, filling out forms correctly, and standing up for your rights if needed.

At @BeshakIN, you can connect with top industry experts at your convenience.  🤍 Don’t believe us? Try it yourself! https://www.beshak.org/advisor...